Serious Injury Report
Fax or Email to ARU at (02) 8005 5681 / and the State Union
A Serious Injury Report must be completed for the following match or training related injuries:
· ANY HEAD OR NECK INJURY THAT RESULTS IN A PLAYER BEING TREATED AT AN EMERGENCY DEPARTMENT, HOSPITAL OR AFTER-HOURS MEDICAL CENTRE, OR
· ANY INJURY THAT RESULTS IN THE ADMISSION OF A PLAYER INTO HOSPITAL.
How to submit this report:
• Accurately record details about the player, their injury, the match and the designated club/school contact below.
• Email or fax within 48 hours of the time of incident to both the Australian Rugby Union and the State Union.
PLAYER (PLEASE PRINT CLEARLY)
Name (in full): MRA ID: DOB: // Age:
Address: Phone Number: ()
Next of Kin: Phone Number: ()
Club/School: Playing Position:
INJURY
Date and Time of Injury: / / at : AM PM Scene of injury: Game Training Other
Site of Injury: Head Neck Back Chest/Trunk Other (specify):
Type of Injury: Concussion Fracture Dislocation Serious Joint Other (specify):
Phase of Play: Tackle Ruck Maul Scrum Lineout Other (specify):
Stage of Game: 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Was the player wearing headgear?: Yes No
Brief description of how
the injury occurred:
Did the player leave the field? Yes No Did the player return to the field? Yes No
Who provided on-field treatment? Doctor First Aid Team Official Other (specify):
Name of treatment provider: Phone Number: ()
What treatment was provided, if any?
How did the player leave the field? Stretcher Ambulance Helicopter Other (specify):
What hospital was the player taken to? Phone Number: ()
Who accompanied the player? Phone Number: ()
MATCH
Teams involved in the match: v
Competition: State Union: Grade:
Referee: Phone Number: ()
Venue Address:
Field Condition: Weather Condition:
How long was the game suspended for?: mins Did the game restart?: Yes No
Is there video footage of the game?: Yes No (If yes, please retain until contacted by the ARU)
CLUB/SCHOOL CONTACT
Name (in full): Position in Club/School:
Contact Numbers: Home: () Mobile: Work: ()
Signature: Date: / /
Privacy Statement: ARU is bound by the Privacy Act 1988 (Cth) and has a Privacy Policy that sets out the permitted use of information including for rugby administration and to provide rugby activities and services. For full details of ARU Privacy Policy visit www.rugby.com.au.
Note, this report IS NOT an ARU Sports Injury Claim Form. For more information contact Gow Gates 1800 811 371 or visit www.rugby.com.au/tryrugby
Serious Injury Report
State Union Fax Numbers:
ACT & SNSW Fax (02) 6260 8591
Queensland Fax (07) 3856 6333
Victoria Fax (03) 9221 0789
New South Wales Fax (02) 9323 3470 South Australia Fax (08) 8231 8066
Western Australia Fax (08) 9387 2804
Northern Territory Fax (08) 8945 2060
Tasmania Fax (03) 6228 0855
Note, this report IS NOT an ARU Sports Injury Claim Form. For more information contact Gow Gates 1800 811 371 or visit www.rugby.com.au/tryrugby
Serious Injury Report
ARU Protocol for Serious Injury
In the event of a serious injury to a players head or neck (ie: suspected spinal injury) or fatality, the following protocol is to be followed:
1. Provide immediate on-field medical care and arrange suitable transportation (ie. ambulance) to the hospital for the injured player.
2. Club/school representative to phone the ARU Serious Injury Case Manager (SICM) on the ARU Hotline 1800 036 156 in the event of a serious injury (ie: suspected spinal injury or fatality). This number is a call back service and your details will be passed on to the SICM who will call you back ASAP. Please have all details of the incident ready to pass on to the SICM.
3. SICM to establish initial contact with designated hotline caller to ascertain current status.
4. SICM notifies ARU General Manager (GM) of Community Rugby or designate of situation.
5. SICM or GM notifies designated representative responsible for zone/region/state union (eg: New South Wales Country Rugby – Executive Officer).
6. Designated representative responsible for zone/region/state is to establish one point of contact with the club/school /zone to coordinate situation (eg: President/Executive Officer).
7. SICM or GM to notify ARU Media Manager.
8. SICM, GM and representative responsible for the zone/region/state to establish a process of support as required.
ARU Serious Injury Case Manager
The Australian Rugby Union (ARU) has appointed a Serious Injury Case Manager (SICM) to assist in managing traumatic injuries. The SICM is your first point of contact in the event of a serious injury to a player’s head or neck (ie: suspected spinal injury) or fatality and will provide a link between the club/school and the Australian Rugby Union (ARU).
Club/School Responsibilities
1. Provide immediate on-field medical care and arrange suitable transportation (ie. ambulance) to the hospital for the injured player.
2. Phone SICM on the ARU Hotline 1800 036 156 in the event of a serious injury (ie: suspected spinal injury or fatality), who in turn notifies ARU nominee.
3. Phone zone/regional/governing affiliate administration.
4. Accurately record any details and persons associated with the injury.
5. Notify next of kin in the case of a serious injury to a players head or neck.
6. In the case of a fatality, the Police will notify the next of kin.
7. Monitor players/match officials (referees, touch judges)/club officials (coaches, managers, runners, trainers, physiotherapists
etc) for team debrief and/or personal counselling.
8. Complete the Serious Injury Report (on the back of this page) and provide copies within 48 hours of the injury occurring to:- (1) Australian Rugby Union – Fax (02) 8005 5681 or Email
(2) State Union –
Note, this report IS NOT an ARU Sports Injury Claim Form. For more information contact Gow Gates 1800 811 371 or visit www.rugby.com.au/tryrugby
Serious Injury Report
ACT & SNSW Fax (02) 6260 8591
Queensland Fax (07) 3856 6333
Victoria Fax (03) 9221 0789
New South Wales Fax (02) 9323 3470
South Australia Fax (08) 8231 8066
Western Australia Fax (08) 9387 2804
Northern Territory Fax (08) 8945 2060
Tasmania Fax (03) 6228 0855
Note, this report IS NOT an ARU Sports Injury Claim Form. For more information contact Gow Gates 1800 811 371 or visit www.rugby.com.au/tryrugby
Serious Injury Report
9. Complete the ARU Sports Injury Claim Form for all insurance claims. For more information please contact Gow-Gates Insurance Brokers (1800 811 371) or visit www.rugby.com.au/tryrugby
State Union Responsibilities
1. Follow up counselling requirements for the injured player, club/school personnel, referee and touch judges in conjunction with SICM and GM.
2. In conjunction with club/school officials, zone/regional/governing affiliate administration and ARU, handle all media contact. There should be one point of contact for media releases.
3. State Union representative to attend any inquest/event.
4. Assist club/school with fund raising activities as required.
ARU Responsibilities
1. Provide support – (logistical and human) to the injured player, family, club/school, match officials, state union as required.
2. Monitor current and ongoing status of the injured player.
3. Complete analysis report of injury occurrence and record on the ARU Serious Injury Register.
4. Maintain ARU database.
Note, this report IS NOT an ARU Sports Injury Claim Form. For more information contact Gow Gates 1800 811 371 or visit www.rugby.com.au/tryrugby